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Diabetic Retinopathy   Dr. Devin Prabhakar MS, DNB, MNAMS, FRCS  Divya Prabha Eye Hospital, Trivandrum 695011           +9...
ObjectivesBy the end of the session participants will  be able to:• Define & classify diabetic retinopathy• List signs and...
drdevin@gmail.com   www.DivyaPrabha.in
Diabetic Eye Diseases•   Diabetic Retinopathy•   Cataract•   Glaucoma•   Refractive errors•   Stye                drdevin@...
When Does Retinopathy ArisePrevalence of DR• At diagnosis 20%• 10 years after diagnosis 40-50%• 20 years after diagnosis  ...
With strict control of DM:• Risk of developing retinopathy was  reduced by 75%• Reduction in the rate of progression of  r...
drdevin@gmail.com   www.DivyaPrabha.in
drdevin@gmail.com   www.DivyaPrabha.in
drdevin@gmail.com   www.DivyaPrabha.in
Microaneurysm• Small protuberances on the retinal blood  vessels. The first sign of eye damage.  Microaneurysms are revers...
Hard Exudates       • Yellow spots seen in the         retinaThey are lipid         break-down products         that are l...
IRMA• Intraretinal microvascular abnormalities  (lRMA) : Dilated, tortous retinal  capillaries that act as a shunt between...
• A) cotton-wool                 spot               • B) venous                 beading               • C) intraretinal   ...
NVD• New Vessels: Unlike IRMA, they arise on  the retinal surface and may extend or be  pulled into the vitreous cavity.• ...
drdevin@gmail.com   www.DivyaPrabha.in
• Fibrous Glial                  proliferation :                  Accompained                  growth of new              ...
drdevin@gmail.com   www.DivyaPrabha.in
Oph. Invest. of dr• Fundus Photography• Fluorescein Angiography  – Guide treatment of CSME to identify    Ischemic maculop...
FFAdrdevin@gmail.com   www.DivyaPrabha.in
drdevin@gmail.com   www.DivyaPrabha.in
OCT• Optical Coherence Tomography OCT  creates cross section of retina. It  demonstrates 3 basic structural changes  of th...
drdevin@gmail.com   www.DivyaPrabha.in
Risk Factors for dr• Duration of diabetes : is the most  important factor.• In patients diagnosed as having diabetes  befo...
RISK FACTORS for dr           •   Age at diagnosis of diabetes           •   Duration           •   Poor control of diabet...
Stages of Retinopathy•   No DR                     • No Macular Edema•   Mild NPDR                 • Macular Edema•   Mod ...
drdevin@gmail.com   www.DivyaPrabha.in
Macular edema types• Focal ME :which has  identifiable leakage  source.• Cystoid ME : in which  fluid accumulate in OPL  a...
drdevin@gmail.com   www.DivyaPrabha.in
CSME (ETDRS):definition           • retinal thickening 500             from fovea           • HE within 500 microns       ...
DME: Pathophysiology• DME is the result of microvascular  changes in diabetes leading to  incompetence of vessels• Hypoxic...
DME: Morbidity• DME is the leading cause of new blindness  in the US .• Untreated , 25-30 % of CSME double their  visual a...
Differential Diagnoses of dr•   ARMD•   Exudative BRVO•   CRVO•   Hypertension•   Macular Edema•   Irvine-Gass Uveitis    ...
Treatment ModalitiesLASER Photocoagulation  CSME – Focal & Grid PDR–  Pan Retinal PhotocoagulationINTRA VITREAL  anti VEGF...
Focal/grid laser• Significant visual improvement is uncommon.  Photocoagulation reduced the risk of moderate  visual loss ...
Deferral of focal laser• Hypertension or fluid retention associated with  heart failure, renal failure, pregnancy, or any ...
Intravitreal triamcinolone            acetonideIVTA has been shown to significantly reduce macular edema and to improve vi...
Rx Intravitreal anti-VEGF              agents• Ocular VEGF increases retinal vascular  permeability, causes breakdown of t...
drdevin@gmail.com   www.DivyaPrabha.in
CSME: Conclusion• Untreated, 25-30% of patients with CSME  exhibit a doubling of the visual angle  within 3 years. Treated...
Ocular Risk Factors Removal of           cataract• DR may progress after cataract surgery.  Patient who have CSME, SNPDR o...
drdevin@gmail.com   www.DivyaPrabha.in
Follow up of dr•   Annually Normal•   Every 9 months Mild NPDR•   Every 6 months Moderate NPDR•   Every 6 months CSME•   E...
drdevin@gmail.com   www.DivyaPrabha.in
Panretinal photocoagulation• The benefit of early panretinal photocoagulation  at the severe nonproliferative or worse sta...
drdevin@gmail.com   www.DivyaPrabha.in
DCCT 1993• 1441 subjects with IDDM followed for 6.5  years. Randomized into strict and  conventional treatment. Strict con...
Glycemic Control• Total lifetime exposure to glycemia  was the principal determinant of the risk  of retinopathy• There is...
Role of BP• Hypertension is an independsant risk  factor for DR and its progression.• UKPDS 1998:  – Tighter control of BP...
Role of cholesterol• WESDR 19914: Higher serum cholesterol  increased risk of HE in type I• ETDRS 1996: Higher serum lipid...
Pregnancy : DRDR accelerate during pregnancy and improve postpartum. Do not hesitate to treat with laser when indicated. F...
Quiz #1 True of False• People with diabetes are more likely than  people without diabetes to develop  certain eye diseases...
#2 True or False• Diabetes eye diseases has early warning  signs• FALSE               drdevin@gmail.com   www.DivyaPrabha.in
#3 True or False• People with diabetes should have yearly  eye examinations• TRUE               drdevin@gmail.com   www.Di...
#4 True or False• Diabetic retinopathy is caused by changes  in the blood vessels in the eye.• TRUE. In some people, blood...
#5 True or False• People with diabetes are at low risk for  developing glaucoma.• FALSE               drdevin@gmail.com   ...
#6 True or False• Laser surgery can be used to halt the  progression of diabetes retinopathy• TRUE. In laser surgery, lase...
#7 True or False• People with diabetes should have regular  eye examination through dilated pupils.• TRUE               dr...
#8 True or False• Cataract are common among people with  diabetes.• TRUE             drdevin@gmail.com   www.DivyaPrabha.in
#9 True or False• People who have good control of their  diabetes are not at high risk for diabetic  eye disease.• FALSE. ...
#10 True or False• The risk of blindness from diabetic eye  disease can be reduced.• TRUE. With early detection and timely...
“We choose our joys andsorrows long before we experience             them.”          ― Kahlil Gibran  www.facebook.com/Dev...
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Diabetic Retinopathy

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  • OCT is not currently required to establish a diagnosis and is not prescribed by current practice guideline; however, OCT has gained widespread acceptance as an additional modality to help identify and evaluate macular pathology. Quantitative measurement of macular thickness and subjective analysis of the foveal architecture allow a precise and reproducible way to monitor macular edema.
  • Transcript of "Diabetic Retinopathy"

    1. 1. Diabetic Retinopathy Dr. Devin Prabhakar MS, DNB, MNAMS, FRCS Divya Prabha Eye Hospital, Trivandrum 695011 +91471-2442050, drdevin@gmail.com
    2. 2. ObjectivesBy the end of the session participants will be able to:• Define & classify diabetic retinopathy• List signs and symptoms of diabetic retinopathy• State why signs & symptoms occur• When referral to an ophthalmologist is required.• Treatment options available drdevin@gmail.com www.DivyaPrabha.in
    3. 3. drdevin@gmail.com www.DivyaPrabha.in
    4. 4. Diabetic Eye Diseases• Diabetic Retinopathy• Cataract• Glaucoma• Refractive errors• Stye drdevin@gmail.com www.DivyaPrabha.in
    5. 5. When Does Retinopathy ArisePrevalence of DR• At diagnosis 20%• 10 years after diagnosis 40-50%• 20 years after diagnosis – Type I 100% – Type II 60% drdevin@gmail.com www.DivyaPrabha.in
    6. 6. With strict control of DM:• Risk of developing retinopathy was reduced by 75%• Reduction in the rate of progression of retinopathy in existing retinopathy 50%• Diabetes Control and Complications Trial Research Group N Engl J Med 1993; 329:977-986. drdevin@gmail.com www.DivyaPrabha.in
    7. 7. drdevin@gmail.com www.DivyaPrabha.in
    8. 8. drdevin@gmail.com www.DivyaPrabha.in
    9. 9. drdevin@gmail.com www.DivyaPrabha.in
    10. 10. Microaneurysm• Small protuberances on the retinal blood vessels. The first sign of eye damage. Microaneurysms are reversible if the blood glucose control is improved drdevin@gmail.com www.DivyaPrabha.in
    11. 11. Hard Exudates • Yellow spots seen in the retinaThey are lipid break-down products that are left behind after localized edema resolves. You can kind of think of them like the dirt-ring that gets left behind after the bathwater drains out. drdevin@gmail.com www.DivyaPrabha.in
    12. 12. IRMA• Intraretinal microvascular abnormalities (lRMA) : Dilated, tortous retinal capillaries that act as a shunt between arterioles and venules. frequently seen adjacent to areas of capillary closure. IRMA may resemble focal areas of flat NVE . But in IRMA : intraretinal location. absence of profuse leakage on fluorescein angiography. failure to cross over major retinal blood vessels. www.DivyaPrabha.in drdevin@gmail.com
    13. 13. • A) cotton-wool spot • B) venous beading • C) intraretinal microvascular abnormalities; • D) intraretinal hemorrhages.drdevin@gmail.com www.DivyaPrabha.in
    14. 14. NVD• New Vessels: Unlike IRMA, they arise on the retinal surface and may extend or be pulled into the vitreous cavity.• NVD : NV appears on or within one DD of disc margin .• NVE : any other location . drdevin@gmail.com www.DivyaPrabha.in
    15. 15. drdevin@gmail.com www.DivyaPrabha.in
    16. 16. • Fibrous Glial proliferation : Accompained growth of new vessels. It is proliferation between the posterior vitreous gel and the ILM. Derived from retinal glial cells anddrdevin@gmail.com fibrocytes. www.DivyaPrabha.in
    17. 17. drdevin@gmail.com www.DivyaPrabha.in
    18. 18. Oph. Invest. of dr• Fundus Photography• Fluorescein Angiography – Guide treatment of CSME to identify Ischemic maculopathy – IRMA vs NV evaluation• Optical Coherence Tomography• USG – B scan drdevin@gmail.com www.DivyaPrabha.in
    19. 19. FFAdrdevin@gmail.com www.DivyaPrabha.in
    20. 20. drdevin@gmail.com www.DivyaPrabha.in
    21. 21. OCT• Optical Coherence Tomography OCT creates cross section of retina. It demonstrates 3 basic structural changes of the retina from diabetic macular edema (DME), that is, retinal swelling, cystoid edema, and serous retinal detachment drdevin@gmail.com www.DivyaPrabha.in
    22. 22. drdevin@gmail.com www.DivyaPrabha.in
    23. 23. Risk Factors for dr• Duration of diabetes : is the most important factor.• In patients diagnosed as having diabetes before the age of 30 years, the incidence of DR : • after 10 years is 50% • after 30 years is 90% drdevin@gmail.com www.DivyaPrabha.in
    24. 24. RISK FACTORS for dr • Age at diagnosis of diabetes • Duration • Poor control of diabetes • Pregnancy • Hypertension • Nephropathy • Hyperlipidemia • Obesity • Anemia • Smoking • Cataract surgery drdevin@gmail.com www.DivyaPrabha.in
    25. 25. Stages of Retinopathy• No DR • No Macular Edema• Mild NPDR • Macular Edema• Mod NPDR Present• Severe NPDR• PDR drdevin@gmail.com www.DivyaPrabha.in
    26. 26. drdevin@gmail.com www.DivyaPrabha.in
    27. 27. Macular edema types• Focal ME :which has identifiable leakage source.• Cystoid ME : in which fluid accumulate in OPL and INL to form cystoid spaces.• Diffuse ME : which has multiple unidentifiable source of leakage. drdevin@gmail.com www.DivyaPrabha.in
    28. 28. drdevin@gmail.com www.DivyaPrabha.in
    29. 29. CSME (ETDRS):definition • retinal thickening 500 from fovea • HE within 500 microns from fovea with thickening • 1500 of thickening with any part within 1 DD of fovea drdevin@gmail.com www.DivyaPrabha.in
    30. 30. DME: Pathophysiology• DME is the result of microvascular changes in diabetes leading to incompetence of vessels• Hypoxic state stimulate VEGF causing more CME drdevin@gmail.com www.DivyaPrabha.in
    31. 31. DME: Morbidity• DME is the leading cause of new blindness in the US .• Untreated , 25-30 % of CSME double their visual angle within 3 years• Treated the risk drops by 50% drdevin@gmail.com www.DivyaPrabha.in
    32. 32. Differential Diagnoses of dr• ARMD• Exudative BRVO• CRVO• Hypertension• Macular Edema• Irvine-Gass Uveitis drdevin@gmail.com www.DivyaPrabha.in
    33. 33. Treatment ModalitiesLASER Photocoagulation CSME – Focal & Grid PDR– Pan Retinal PhotocoagulationINTRA VITREAL anti VEGF – Bevacizumab, Ranibizumab steroids – Triamcinolone acetonidePARS PLANA VITRECTOMY drdevin@gmail.com www.DivyaPrabha.in
    34. 34. Focal/grid laser• Significant visual improvement is uncommon. Photocoagulation reduced the risk of moderate visual loss from diabetic macular edema by 50%, from 24% to 12%, 3 years after initiation of treatment.• Laser treatment is most effective when initiated before visual acuity is lost. Laser treatment of diabetic macular edema should precede panretinal photocoagulation (PRP) by at least 6 weeks because PRP before has been known to worsen diabetic macular edema. PRP should not be delayed in patients with very severe nonproliferative diabetic retinopathy or high-risk proliferative diabetic retinopathy drdevin@gmail.com www.DivyaPrabha.in
    35. 35. Deferral of focal laser• Hypertension or fluid retention associated with heart failure, renal failure, pregnancy, or any other causes that may aggravate macular edema.• when the center of the macula is not involved, visual acuity is excellent, and the patient understands the risks• Treatment of lesions close to the foveal avascular zone may result in damage to central vision and with time laser scars may expand and cause further vision deterioration. drdevin@gmail.com www.DivyaPrabha.in
    36. 36. Intravitreal triamcinolone acetonideIVTA has been shown to significantly reduce macular edema and to improve visual acuity, particularly. Action is maximal at 1 week, lasting 3-6 months. Patients should be counseled about the risk (30-40%) of increased intraocular pressure, of which virtually all can be medically controlled. Other adverse effects include a less than 1% chance of retinal detachment, cataract, and endophthalmitis drdevin@gmail.com www.DivyaPrabha.in
    37. 37. Rx Intravitreal anti-VEGF agents• Ocular VEGF increases retinal vascular permeability, causes breakdown of the blood-retina barrier, and results in retina edema. VEGF is up-regulated in diabetic retinopathy. Three currently available anti-VEGF agents are pegaptanib sodium, ranibizumab, and bevacizumab drdevin@gmail.com www.DivyaPrabha.in
    38. 38. drdevin@gmail.com www.DivyaPrabha.in
    39. 39. CSME: Conclusion• Untreated, 25-30% of patients with CSME exhibit a doubling of the visual angle within 3 years. Treated, the risk drops by 50%. drdevin@gmail.com www.DivyaPrabha.in
    40. 40. Ocular Risk Factors Removal of cataract• DR may progress after cataract surgery. Patient who have CSME, SNPDR or PDR should undergo photocoagulation if the media is sufficiently clear.• If the cataract preclude retina evaluation and treatment, prompt postoperative retinal evaluation and treatment should considered drdevin@gmail.com www.DivyaPrabha.in
    41. 41. drdevin@gmail.com www.DivyaPrabha.in
    42. 42. Follow up of dr• Annually Normal• Every 9 months Mild NPDR• Every 6 months Moderate NPDR• Every 6 months CSME• Every 4 months Sever NPDR• Every 2- 4 months CSME• Every 2-3 months PDR drdevin@gmail.com www.DivyaPrabha.in
    43. 43. drdevin@gmail.com www.DivyaPrabha.in
    44. 44. Panretinal photocoagulation• The benefit of early panretinal photocoagulation at the severe nonproliferative or worse stage of retinopathy is greater in patients with type 2 diabetes than in those with type 1.• Other factors, such as poor compliance with follow-up, impending cataract extraction or pregnancy, and status of fellow eye will help in determining the timing of the panretinal photocoagulation.• It is preferable to perform the focal photocoagulation first, prior to panretinal photocoagulation to prevent laser-induced exacerbation of the macular edema drdevin@gmail.com www.DivyaPrabha.in
    45. 45. drdevin@gmail.com www.DivyaPrabha.in
    46. 46. DCCT 1993• 1441 subjects with IDDM followed for 6.5 years. Randomized into strict and conventional treatment. Strict control group had average hbA1c 7.2% Conventional 8.8%• Strict control resulted in reduction of retinopathy by 76%• Reduced risk of progression by 54% drdevin@gmail.com www.DivyaPrabha.in
    47. 47. Glycemic Control• Total lifetime exposure to glycemia was the principal determinant of the risk of retinopathy• There is no level ofglycemic control below which a reduction in risk does not occur. Improved control always reduced risk of retinopathy retinmopathy drdevin@gmail.com www.DivyaPrabha.in
    48. 48. Role of BP• Hypertension is an independsant risk factor for DR and its progression.• UKPDS 1998: – Tighter control of BP resulted in 34% reduction in progression of DR. – 47% reduced risk of loss 3 lines VA drdevin@gmail.com www.DivyaPrabha.in
    49. 49. Role of cholesterol• WESDR 19914: Higher serum cholesterol increased risk of HE in type I• ETDRS 1996: Higher serum lipids increased risk of HE and loss of VA• Elevated lipids may increase the morbidity of diabetic macular edema. drdevin@gmail.com www.DivyaPrabha.in
    50. 50. Pregnancy : DRDR accelerate during pregnancy and improve postpartum. Do not hesitate to treat with laser when indicated. FFA should be avoided in all but the most difficult cases of macular edema. drdevin@gmail.com www.DivyaPrabha.in
    51. 51. Quiz #1 True of False• People with diabetes are more likely than people without diabetes to develop certain eye diseasesTrue drdevin@gmail.com www.DivyaPrabha.in
    52. 52. #2 True or False• Diabetes eye diseases has early warning signs• FALSE drdevin@gmail.com www.DivyaPrabha.in
    53. 53. #3 True or False• People with diabetes should have yearly eye examinations• TRUE drdevin@gmail.com www.DivyaPrabha.in
    54. 54. #4 True or False• Diabetic retinopathy is caused by changes in the blood vessels in the eye.• TRUE. In some people, blood vessels in the retina may swell and leak fluid. In other people, abnormal new blood vessels grow on the surface of the retina. drdevin@gmail.com www.DivyaPrabha.in
    55. 55. #5 True or False• People with diabetes are at low risk for developing glaucoma.• FALSE drdevin@gmail.com www.DivyaPrabha.in
    56. 56. #6 True or False• Laser surgery can be used to halt the progression of diabetes retinopathy• TRUE. In laser surgery, laser light is used to shrink the abnormal vessels or seal leaking blood vessels. Laser surgery has been proven to reduce the 5 year risk of vision loss from advanced retinopathy by more than 90% drdevin@gmail.com www.DivyaPrabha.in
    57. 57. #7 True or False• People with diabetes should have regular eye examination through dilated pupils.• TRUE drdevin@gmail.com www.DivyaPrabha.in
    58. 58. #8 True or False• Cataract are common among people with diabetes.• TRUE drdevin@gmail.com www.DivyaPrabha.in
    59. 59. #9 True or False• People who have good control of their diabetes are not at high risk for diabetic eye disease.• FALSE. Even with good control of blood glucose, there is still a risk of developing diabetic eye disease. However studies have shown that careful management of blood sugar levels slows the onset and progression of diabetic retinopathy. drdevin@gmail.com www.DivyaPrabha.in
    60. 60. #10 True or False• The risk of blindness from diabetic eye disease can be reduced.• TRUE. With early detection and timely treatment, the risk of blindness from diabetic eye disease can be reduced. drdevin@gmail.com www.DivyaPrabha.in
    61. 61. “We choose our joys andsorrows long before we experience them.” ― Kahlil Gibran www.facebook.com/DevinPrabhakar drdevin@gmail.com www.DivyaPrabha.in

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